Comparison of Transverse Friction Massage and Instrument- Assisted Soft-Tissue Mobilization in Plantar Fasciitis

Plantar fasciitis is a musculoskeletal condition of the foot. It is characterized by pain and tenderness at the medial plantar heel, particularly during first steps in the morning or after inactivity. Pain may worsen with prolonged standing or weight bearing and can affect walking, standing, occupational activities. The condition is multifactorial, with factors including prolonged standing, repetitive loading, running, reduced ankle dorsiflexion, flat-foot posture, and lower-limb biomechanical abnormalities. Physiotherapy is central to conservative management and commonly includes stretching, strengthening, orthotic interventions, taping, electrotherapy, and manual therapy. However, there is no universally accepted gold-standard intervention, and outcomes may vary because of differences in treatment protocols, dosage, and patient characteristics. Transverse Friction Massage (TFM) is a manual therapy technique involving deep transverse mechanical forces across affected tissues. It is intended to improve tissue mobility, address adhesions, stimulate local circulation, and promote tissue remodeling. Its effectiveness may depend on therapist skill, pressure, and treatment duration. Repetitive manual pressure, particularly through the therapist's thumb, may contribute to fatigue and work-related musculoskeletal strain. Instrument-Assisted Soft-Tissue Mobilization (IASTM) uses a specialized instrument to apply controlled mechanical pressure to soft tissues. It is intended to improve tissue mobility, stimulate mechanotransduction and fibroblast activity, enhance local blood flow, and promote tissue remodeling. Evidence has reported potential benefits for pain, flexibility, and functional outcomes in musculoskeletal conditions, although protocols and outcome measures vary. IASTM may also reduce repetitive loading on the therapist's thumb and hand. Comparative evidence between TFM and IASTM in plantar fasciitis remains limited, supporting the need for this study. The studyaims to compare the effectiveness of TFM and IASTM in patients with plantar fasciitis. It will be conducted as a randomized trial at Foundation University College of Physical Therapy, Islamabad, over one year after synopsis approval, from February 2026 to January 2027. Participants diagnosed with plantar fasciitis who fulfill the eligibility criteria will be recruited from Fauji Foundation Hospital after receiving information about the study. Purposive Sampling will be used for recruitment. The calculated sample size is 34 participants, with 17 participants in each group. It was calculated using G*Power with an effect size of 0.31, alpha error of 5%, and power of 95%, with two groups and three measurements with a 10% attrition rate. Participants will be randomly allocated to Group A or Group B through sealed opaque envelopes. A research assistant not involved in treatment will perform the allocation. The study will include males and females aged 19-44 years with plantar medial heel pain that is noticeable during initial steps after inactivity and may worsen with prolonged weight bearing. Participants must have symptoms for more than three months and a clinical diagnosis of plantar fasciitis. Clinical findings include a positive Windlass test and limited active and passive talocrural dorsiflexion. Exclusion criteria include previous plantar fasciitis surgery, congenital foot abnormalities, systemic lower-extremity disorders, peripheral neuropathy, other foot disorders, contraindications to IASTM, inability or unwillingness to follow study procedures, pregnancy, immunosuppression, peripheral vascular disease, thrombocytopenia, anticoagulant therapy, and post-mastectomy status. Demographic information including age, gender, weight, height, and medical history will be recorded. Outcomes will include pain intensity, foot-related functional impairment, and ankle range of motion. Pain will be assessed using the Numeric Pain Rating Scale (NPRS), scored from 0 to 10, withhigher scores indicating greater pain. Foot function will be assessed using the Foot Function Index (FFI). Ankle range of motion will be measured with a goniometer. Group A will receive TFM with the standardized protocol. Participants will be positioned supine, the most painful plantar fascia insertion will be identified, and the foot will be dorsiflexed. Deep friction massage will be applied using a reinforced index finger transversely and perpendicular to the tissue fibers, within participant tolerance, for approximately five minutes. Group B will receive IASTM with the same standardized protocol. Treatment will begin with a three-minute cycling or walking warm-up. Participants will be positioned prone with the involved knee flexed to 90 degrees and the ankle neutral. An emollient will be applied to the plantar surface, followed by six minutes of IASTM. Sweeping and fanning strokes will be performed from the calcaneus toward the metatarsal heads, with the instrument held at approximately 45 degrees to the skin. Pressure will be adjusted according to comfort. Both groups will receive standardized stretching, strengthening, ultrasound therapy, and home exercises. Stretching will include plantar fascia, gastrocnemius, soleus, and towel stretches. Ultrasound will use 3 MHz frequency, 1.2-1.5 W/cm² intensity for subacute or chronic presentations, continuous mode, and 5-8 minutes per session, twice weekly for four weeks. Strengthening will progress from towel scrunches, marble pickups, and short-foot exercises during weeks 1-2 to eccentric heel drops, resisted plantarflexion and dorsiflexion, supported single-leg heel raises, and toe-spreading or resisted toe-flexion exercises during weeks 3-4. Treatment will be provided twice weekly for four weeks, resulting in eight sessions. Assessments will occur at baseline, after two weeks, and after four weeks. The study will be single blinded. Because of nature of the interventions, participants and the treating physiotherapist cannot be blinded; however, the outcome assessor will remain blinded to group allocation. Data will be analyzed using IBM SPSS Version 21. The Shapiro-Wilk test will assess normality, and parametric or non-parametric statistical tests will be selected according to data distribution. Qualitative data will be presented as frequencies and percentages, while quantitative data will be summarized using mean and standard deviation or median and interquartile range, as appropriate. Statistical significance will be set at p<0.05 with a 95% confidence interval. Ethical approval will be sought from the Ethical Review Committee of Foundation University, Islamabad. Written informed consent will be obtained from all eligible participants after explanation of the study procedures and data collection. Participants may withdraw at any stage. Confidentiality will be maintained, and study data will be securely stored. The study will compare TFM and IASTM for pain, foot function, and anklerange of motion in patients with plantar fasciitis. By evaluating outcomes at baseline, two weeks, and four weeks, the study aims to determine whether either technique produces greater improvement when combined with a standardized physiotherapy protocol. Findings may guide evidence-based management.